Risk management in clinical IN BRIEF

• Endodontics is an area of dentistry which

practice. Part 4. Endodontics gives rise to an increasing amount of

PRACTICE
complaints and litigation.
• Warning patients about the risks
associated with endodontics is an
J. Webber1 important part of obtaining valid consent.
• Where treatment will be complex a
referral to a specialist should be offered.
VERIFIABLE CPD PAPER

Endodontic procedures are challenging and technically demanding. In the UK standards of treatment have been shown
to have fallen short of acceptable guidelines, laying many dentists open to litigation on questions of clinical negligence
by patients who understand and know what should be considered as current best practice in this area. Failure to com-
municate with patients about the procedure and not obtaining consent for treatment is a key area of complaint, as is
inadequate record keeping. When treatment is undertaken within the framework of accepted guidelines it would be very
difficult for a patient to open a claim for clinical negligence should a failure occur. This article looks at potential dento-
legal problems in endodontics and how, through compliance with best practice, they may be avoided.

It is widely accepted that for many gen- prevalence of endodontic infection there- practitioners and interviewed a cross sec-
eral dental practitioners the practice of fore remains high, with many treatment tional population of 12 dental practitioners
endodontics is challenging and techni- failures,1–7 thus providing excellent ammu- to assess compliance of some of the param-
cally demanding. An unfortunate corol- nition for our implant colleagues. eters within the framework of the ESE
lary to this is that on a worldwide basis the In the UK, these problems have been guidelines in terms of treatment provided.
standard of endodontic treatment provided highlighted by research on endodontics Practitioners were interviewed on their
and its technical quality is poor and the in the NHS, which is often regarded as compliance with the following: was rubber
falling short of what is considered as cur- dam used for all endodontic procedures?
RISK MANAGEMENT rent best practice within the framework Were radiographs taken to guide operative
IN CLINICAL PRACTICE of guidelines published and laid down by treatment, and to monitor tissue response
the European Society of Endodontology to treatment? Were prepared canals filled
1. Introduction
(ESE).8,9 Dummer showed that only 10% of with a semi-solid material (gutta percha) in
2. Getting to ‘yes’ – the matter of consent
cases treated by UK general dental practi- combination with sealer rather than solid
3. Crowns and bridges
tioners could be considered as acceptable materials such as silver points or sealers
4. Endodontics
with reference to the ESE guidelines.10,11 containing strong organic compounds
5. Ethical considerations for dental
enhancement procedures The ESE quality guidelines provide a such as aldehydes? Was treatment moni-
6a. Identifying and avoiding medico-legal statement of good practice for dentists tored clinically and radiographically after
risks in complete denture prosthetics about to embark on endodontic treatment treatment and success determined on the
6b. Identifying and avoiding medico-legal and, perhaps more importantly for patients, basis of tissue response and not just the
risks in removable dentures a greater understanding of the procedure abolition of reported symptoms?
7. Dento-legal aspects of orthodontic they are about to have. The guidelines Only a third of the group, which included
practice
include recommendations on: more recent graduates, principals and
8. Temporomandibular disorders
• History, diagnosis and treatment associates, demonstrated a high level of
9. Dental implants
planning compliance with ESE guidelines, while the
10. Periodontology
• Record keeping rest of the group interviewed demonstrated
11. Oral surgery
• Infection control an intermediate to low level of compli-
• Maintenance of pulp vitality ance. The reasons for non compliance
1
Specialist Endodontist, Director, The Harley Street • Root canal treatment were varied.
Centre for Endodontics, 121 Harley Street, London,
W1G 6AX • Endodontic surgery Jenkins, Hayes and Dummer 13 looked at
Email: jw@julianwebber.com • Assessment of endodontic treatment the nature of root canal treatment carried
www.roottreatmentuk.com
• Management of traumatic injuries. out by a group of dentists working in the
Refereed Paper UK. The majority of practitioners did not
Accepted 20 October 2009
DOI: 10.1038/sj.bdj.2010.721 McKoll et al.12 looked at the barriers to use rubber dam. Many did expose a ‘length’
© British Dental Journal 2010; 209: 161–170
improving endodontic care among NHS radiograph and most practitioners used

BRITISH DENTAL JOURNAL VOLUME 209 NO. 4 AUG 28 2010 161

© 2010 Macmillan Publishers Limited. All rights reserved

PRACTICE

local anaesthetic as an irrigant rather than

sodium hypochlorite. The majority used a
potentially irritating antiseptic solution as
an inter-appointment medicament rather
than calcium hydroxide. Lateral condensa-
tion was used by half the surveyed den-
tists to fill anterior canals but only one
third used it in posterior teeth. Only half
checked the fit of the master cone before
a b
obturation. Two thirds used a zinc oxide
based sealer and three quarters took a final
post obturation radiograph. The authors
concluded that a large percentage were
using techniques with no evidence of
clinical effectiveness.
What does all this suggest from a dento-
legal standpoint? Many dentists in the UK,
and elsewhere, where outcomes are poor
are laying themselves open to litigation
c d
from patients who increasingly will know
what treatment they should have received
rather than what they actually did, with an
inevitable rise of clinical negligence claims
in this field.

PRINCIPLES OF CONSENT
AND ENDODONTICS
The UK General Dental Council (GDC) has
laid down guidelines on the question of
standards of treatment by dentists and
principles of patient consent.14,15 These
issues are as appropriate to the practice of
endodontics as any other branch of den-
tistry and have been dealt with elsewhere
in this series. However, one of the major
causes of litigation in endodontics occurs
as a result of failure to make the patient
aware of all the facts before commenc-
ing treatment and with this, a failure to
receive consent from the patient that they
are happy for the treatment to go ahead.
Field et al. and Lazarski et al. showed
that although high, 100% successful out-
comes do not exist in endodontics, even
in the best hands.16,17 Patients need to be
made aware of and understand the com-
plexities of treatment as well as the pos-
sibility of failure and the reasons behind
this. It is too late to discuss failure with a
patient after it has occurred.
Patients should be given the option of
referral to an endodontist for difficult cases,
especially where the practitioner is not
skilled enough (Figs 1a-f). The American
Association of Endodontists has produced
guidelines to help general dentists under-
stand case difficulty.18 The suggestion that
e f
Fig. 1 a) Anatomically complex 35 requires retreatment; a suitable case for referral?
b) Completed case 35 demonstrates three canals. Apical bifurcation extremely difficult to
prepare and fill. c) 46 complex retreatment with crown, two posts, inadequate root canal
treatment, apical area distally and separated instrument in MB canal; a suitable case for
referral. d) 46 retreated successfully. e) 46 complex anatomy also apparent. Three mesial and
three distal canals are present. f) 46 one-year recall, tooth restored and healing seen
the endodontic treatment cannot be car- treatment can result in a weaker tooth that
ried out under the health service contract will most probably require cuspal coverage
is unacceptable and there are NHS as well following the endodontic treatment. Since
as private specialists who accept referrals. endodontically treated teeth can discolour
The suggestion that a high standard can- this should also be discussed, as should the
not be achieved by a dentist because of possible solutions.
financial constraints is also unacceptable. The patient notes should reflect all of
Every dentist has a duty of care to do the these scenarios and that these discussions
best he or she can within the guidelines of have taken place. Where necessary and
best practice. If the dentist can demonstrate in the case of private treatment, patients
that treatment was undertaken within the should ideally be given a written quote for
framework of accepted guidelines, any fail- treatment and within the body of the cor-
ure, should it occur, can be defended. respondence, a list of the issues involved
We all know that endodontics can be that could possibly lead to failure. In stat-
uncomfortable after completion and it is ing that endodontic treatment can never
therefore prudent to anticipate this by advis- be 100% successful it is wise not to give
ing what can be done to alleviate the symp- a percentage estimate of probable suc-
toms. Again, this is best explained before cess, stating instead that there is a very
treatment, as is the fact that endodontic good chance that treatment will lead to

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© 2010 Macmillan Publishers Limited. All rights reserved


Fig. 2 The Digital Office: single tooth endodontic diagnosis page. (Courtesy of Dr Gary Carr,
Dogbreath Software, San Diego, California, USA)
the desired outcome of tooth retention and
elimination of infection. If the tooth is not
periodontally compromised and is restora-
tively saveable then good outcomes can
be expected. Teeth that receive good root
treatments with adequate coronal restora-
tions are just as likely to survive as implant
retained restorations, as a review article
from Iqbal and Kim has clearly shown.19
According to Friedman and Mor, function-
ality is an acceptable terminology to meas-
ure outcome of root treated teeth.20
DENTO-LEGAL PROBLEMS
IN ENDODONTICS
The following issues will be discussed
as potential areas of litigation in
endodontics:
• Misdiagnosis of pain and treatment of
the wrong tooth
• Why did the tooth develop pulpitis and
who was responsible?
• Good radiographic technique
• Rubber dam
• Why did a tooth fracture after
treatment?
• The question of broken (separated)
instruments
• Root canal instruments: single use
• Hypochlorite accidents
• Obturation problems: the question of
underfilling and overextension versus
overfilling of the root canal system
• Perforations.
Diagnosis
The biggest issue in endodontic diagno-
sis is failure to locate the cause of pain
BRITISH DENTAL JOURNAL VOLUME 209 NO. 4 AUG 28 2010
resulting in the wrong tooth being treated.
A systematic approach is required to make
the correct diagnosis and all stages of the
diagnostic procedure must be recorded in
the patient notes. Many endodontists will
use a diagnostic chart which includes a
list of patient symptoms and details of the
radiographic, oral and individual tooth
examinations (Fig. 2).
Endodontic emergency treatment is
required when a diagnosis of irreversible
pulpitis is made, which is invariably asso-
ciated with temperature sensitivity that
lingers and pain on biting. All teeth in the
same and opposing quadrant should be
examined using ice and heat. Cartridges
of ice can be made up from spent needle
cases filled with water and placed in the
freezer (Figs 3a and b). Heat can be gener-
ated using molten gutta percha (GP) on a
plugger tip at 300°C while the patient bites
on a cotton wool roll. The response from
each tooth should be recorded separately.
A radiograph complements the diag-
nostic tests and should be taken after all
the tests and clinical examinations have
been completed. Treatment should never
be instigated based on symptoms alone.
Other questions to be asked include: is
there a large restoration? Is there car-
ies and a near exposure? Does the peri-
odontal ligament space appear normal
or thickened? These comments assume a
good radiographic technique, exposure
and development (manually or digitally)
that shows the entire tooth undistorted and
with all supporting structures clearly seen
(Figs 4a-d). The golden rule is only to start
© 2010 Macmillan Publishers Limited. All rights reserved
PRACTICE
Fig. 3a Individual sticks of ice made from
used needle cases
Fig. 3b Sticks of ice testing individual teeth
for sensitivity to cold
treatment when the diagnostic tests evoke
a reproducible response which is the same
as that which the patient complained of.
If the response is not reproducible do not
guess. Sometimes acute pulpal symptoms
take time to localise and it is reasonable
to invite the patient to return the next day
so that the tests can be redone in order to
ensure the right tooth is treated.
Many instances of acute pulpal and peri-
apical symptoms occur after a recent res-
toration, small or large, and it is important
to take the time to carry out an extensive
endodontic examination, including radio-
graphs, before a restoration. If it is pos-
sible to demonstrate that the state of the
pulp is compromised before the prepara-
tion and restoration of a tooth then endo-
dontics should be considered in advance.
Abou Rass has called this situation the
‘stressed pulp’.21 It is always far better to
undertake the endodontics first rather than
have a problem after the restoration has
been placed.
Many complaints arise when restora-
tions are placed – either fillings or fixed
restorations – and pulpal pain results
shortly thereafter. If an assessment of the
pulp suggests this may be a possibility it
is important to warn the patient of this
before placing the restoration, or at least
immediately it is placed. Record this warn-
ing in the notes.
163
PRACTICE

a b

Fig. 5 Analytic Technology Pulp Tester

(Sybron Endo), necessary diagnostic
armamentaria
c d

Fig. 4 a) Patient complained of severe sensitivity to cold with lingering pain in the 24,5,6
region. No radiographs or clinical tests were undertaken. 24 was root treated. Pain remained
after treatment. 25 had gross caries. b) Clinically 25 had no obvious external evidence of a
problem but was exquisitely tender to cold. c) 25 with gross caries. d) Root canal treatment
25 complete. Symptoms eliminated but patient had two root treatments instead of one!

Teeth with extreme readings when using
an electric pulp tester to assess pulp vital-
ity (Fig. 5) should be investigated further
before complex restorative work since if
a tooth is nearly dead before the prepara-
tion, it surely will be after the restoration
is placed. Many apparently vital teeth will
become non-vital over a period of time
when extensively restored.22 Invariably,
this problem happens after the restoration
is placed and not during the temporary
stage. This situation can be pre-empted
before the crown, onlay, bridge or veneer
is placed since there is nothing worse for a
patient than to have their expensive crown
ruined by an endodontic access cavity,
especially if recently placed.
Radiographic technique
Poor radiographic technique can be
avoided with appropriate care. Guesswork
using the bisecting angle technique that
distorts the length and curvature of the
roots and does not demonstrate endodon-
tic pathology adequately is an invitation
to poor diagnosis. Many aiming and locat-
ing devices are available today to ensure
a reproducible technique and while digital
radiographs are quick to view (instant), any
manual developing technique must ensure
the film is accurately processed, washed
and dried.
To defend oneself with a poor radio- Fig. 6a Poor radiographic technique
demonstrates little, least of all periapical
graph is like going into battle without any status of upper left quadrant
armour. Quite simply if the radiograph is
poorly developed, does not provide the
correct information or is impossible to
interpret, mounting a defence based on it
would be ill-advised (Figs 6a and b).
Good radiographic technique must also
be applied to the question of length con-
trol in endodontic treatment. A radiograph
with an instrument in the canal and/or a
gutta percha cone at the correct length
indicates that every effort has been made
to ensure that root filling material is not
inadvertently extruded through the apex Fig. 6b Good long cone periapical radiograph
of upper left demonstrating restorative,
of a tooth to a degree whereby the out- periodontal, endodontic and apical status of
come could be undermined (see below). all teeth in region
The length of the canal must be recorded
in the patient record. answer is therefore yes, but the reality is
Whether electronic apex locators (EAL) that where the result is a root filling that
can be used as the sole means of length is very short or indeed very long and there
determination without a radiograph is an is no evidence of any radiographic length
interesting question, as they are widely control, the excuse that an EAL was used
used in endodontics and are very accurate. (even though the literature suggests that
Shabahang et al.23 tested the accuracy of these devices are accurate) and the radio-
the Root ZX apex locator (J. Morita) and graphic reality suggests a poor result would
showed it to be accurate in up to 96% of be indefensible. It is therefore impera-
cases in locating the apical foramen. The tive to always take a control radiograph

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 PRACTICE

a b

Fig. 8a 36 with poorly fitting crown, caries

and apical area

c d
Fig. 7 a) Root ZX electronic apex locator (J Morita, Japan). b) 24 requires root canal
treatment. c) Canals prepared without working length radiograph but EAL was used. The
length was confirmed with a master cone radiograph. d) 24 root canal treatment complete

with an instrument and/or a gutta percha Fractured teeth

cone (Figs 7a-d).
Rubber dam
Nowhere is the use of rubber dam more rel-
evant than in the practice of endodontics.
However, it is seldom used for endodon-
tics despite the knowledge that it ensures
an aseptic environment and entirely pre-
vents ingestion of instruments.24,25 There
are no situations where rubber dam can-
not be applied and general practition-
ers should take the time to learn how
to place rubber dam correctly and avail
themselves of one of the many courses
on placement.
Rubber dam serves to protect the airway
as well as preventing caustic solutions
such as hypochlorite being inadvertently
ingested. In the absence of rubber dam it
is impossible to defend a claim where a
patient has swallowed or inhaled a hand
file. Rotary files are increasingly being
used, but hand files are still required in
most protocols for initial instrumenta-
tion and can be swallowed or inhaled
during canal instrumentation or expo-
sure of radiographs unless rubber dam
is used.
The majority of teeth requiring root treat-
ment invariably have large restorations to
start with. It must be assumed that an endo-
dontic access cavity would further weaken
such a tooth and there is certainly much lit-
erature to support this statement. Therefore, Fig. 8b 36 successfully root treated. Restored
with post core and crown. Excellent healing
in order to prevent a root filled tooth from at one year
fracturing, it should be adequately restored
after the procedure with a post where neces-
sary and the minimal requirement of cuspal
coverage (Figs 8a and b).26–28
With this knowledge, before endodon-
tic treatment all patients should be made
aware of the possibility of tooth fracture
after the procedure and the need to have
the correct restoration. All of this informa-
tion must be recorded in the patient record
along with information to show that the
patient clearly understood the potential
problems should the tooth not be restored Fig. 9 Catastrophic fracture 36 despite
properly. In addition, the need for a good excellent root canal treatment and restoration
restoration to provide adequate coronal
seal as part of an endodontic-restorative the correct restoration, acquired endodon-
continuum must be stressed. There is a tic infection can be expected to occur and
considerable body of literature on this failure is eventually likely.
issue but the reality is that root filled teeth A tooth which is well root filled and
leak from coronal to apical as much as adequately restored can of course sadly
they do from apical to coronal.29 Without fracture at a late stage (Fig. 9). If the

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© 2010 Macmillan Publishers Limited. All rights reserved

PRACTICE

patient has been advised of the restora-

tive requirements of a root filled tooth and
then received a correctly and adequately
placed restoration (bonded core and/or
cuspal coverage) and this unfortunate sce-
nario occurs, the question of negligence
and litigation cannot occur. Conversely, a
poorly advised patient with little or barely
adequate post-endodontic work would
a b
have a suitable case for negligence should
a root filled tooth subsequently fracture.
The timing of the placing of extra-coronal
restorations after endodontics is the sub-
ject of some debate.
A clinical study by Nagasiri and
Chitmongkolsuk 30 showed that sur-
vival rates of endodontically treated
molars without crowns at 1, 2, and
5 years were 96%, 88% and 36%, respec-
tively. With greater amounts of coronal
c d
tooth structure remaining, the survival
probability increased.
Fig. 10 a) 16 fractured instrument in
Broken (separated) instruments coronal of DB canal. b) 16 clinical view
of fractured instrument. c) 16 instrument
Any metal instrument when used in a root retrieved. Four canals shaped, cleaned and
canal is subject to breakage. All metals can filled successfully. d) Three rooted 14 with
fractured instruments in palatal and MB
be stressed beyond their modulus of elas-
canal. e) Palatal instrument retrieved, MB
ticity and at this stage are prone to separa- instrument left in situ and sealed coronally
tion The advent of nickel titanium in rotary by GP and sealer. DB canal found and all
root canal preparation has further com- canals shaped, cleaned and filled successfully
pounded this problem despite the excellent
e
flexibility of these files (Figs 10a-e).
Root canal instruments fail for two
reasons: either flexural fatigue, which
occurs mainly due to instrument overuse, is required to provide 16:1 or 20:1. situation. It is indefensible not to inform a
or torsional fatigue, which occurs due to Attempting to run a rotary instrument on patient if instruments are separated in root
the forces on the instrument in rotation a 1:1 handpiece is an invitation to disaster. canals or beyond them. Ensure all facts are
preventing movement, locking and frac- Should fracture occur it would be indefen- recorded in the patient record and that the
ture.31–33 Pruett et al.34 looked at the issue sible should a patient wish to pursue the patient has understood the implications
of ‘cyclic fatigue’ and concluded that all matter as negligence. If general practition- of any discussion. The patient should be
rotary nickel titanium (RNT) instruments ers are to use these instruments success- advised of the options which may include
have a finite number of rotations to failure. fully, then the manufacturers’ guidelines monitoring and referral to specialist.
Simply put, the more you use an instrument should be adopted and there can be no An instrument that breaks early in the
the more likely it is to fracture. Torsional exception to this. procedure assumes the canal is not clean.
failure occurs when a rotating instrument This leads us to one of the most frequent Failure is likely, unless the instrument can
is placed into a canal that has not been causes of litigation in endodontics: failure be removed. An instrument that fractures
scouted and preflared by hand ISO files to notify a patient that an instrument has at the end of the procedure assumes the
first. Attempting to force an instrument fractured. When all the guidelines have canal has been cleaned, especially if the
into this tight situation will result in taper been followed and overuse is not an issue, instrument is apically positioned. Saunders
lock and subsequent fracture. instruments can still fracture. Operator et al.37 have shown that a sufficiently large
Rotating rotary instruments should experience is a consideration here but the instrument separated apically and then
also be used with a suitable endodontic fact of the matter is that if an instrument sealed with gutta percha and an approved
motor, preferably with torque control to breaks (call it separation if you wish), the sealer will prevent bacterial leakage.
eliminate these dangerous forces but also patient must be informed. In addition, an Furthermore, location also dictates whether
to restrict the number of rotations.35,36 The explanation of the potential problems as a it could or should be removed.
majority of RNT instruments should run result of this incident must be given as well Not all broken instruments can be
at 250-350 rpm and a reducing handpiece as what you are able to do to rectify the removed and some can be left. A strategy

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© 2010 Macmillan Publishers Limited. All rights reserved


is needed to make a decision as to what is
the best way forward.38 Who should make
the decision? Under the circumstances a
referral to a specialist would be advisable
and the final decision should be theirs.
If the referral is private you may wish
to offer to pay for any consultation and
subsequent treatment, but the practitioner
should always check with their defence
society before taking such a step. It is not
an admission of negligence if you offer
to pay, more of an effort to demonstrate
your care and concern that the patient
will be comfortable and that their tooth
is saved.
It is not negligent to separate an instru-
ment in a canal but failing to inform the
patient and manage it appropriately may
well be.
Single use of endodontic
files and reamers
The Chief Dental Officer’s advice on the
single use of endodontic files and reamers
that have been in contact with pulpal tis-
sue39 underlines concerns of the possible
transmission of variant Creutzfeldt-Jakob
disease from patient to patient via this
route despite the very best cleaning and
disinfection procedures. This is a concern
for the future health of the UK public
despite the lack of any real evidence.40
However, all GDPs and specialists, NHS
or private, are expected to follow these
guidelines with no exception. The guide-
lines are open to interpretation and dentists
must review their own decontamination
and sterilising procedures in relation to
items other than files and reamers (spe-
cifically mentioned), such as Gates Glidden
drills, burs and clamps, and re-use these
products only where they are satisfied the
risk element is minimal. It is a matter of
conjecture should there be a challenge on
this issue as to where a dentist would stand
since the recommendation states endodon-
tic files and reamers only.
It has been suggested that endodontic
files and reamers can be re-used on the
same patient. If a clinician stores used
instruments or a patient retains them for
future use, either scenario would be a
breach of the Hazardous Waste Regulations
2005.41 Sharps have to be stored in
clearly labelled boxes and if the dentist
is the producer of the hazardous waste
it is therefore his/her responsibility to
BRITISH DENTAL JOURNAL VOLUME 209 NO. 4 AUG 28 2010
dispose of and not retain this. It is not the
patient’s responsibility.
Hypochlorite accidents
Spencer et al.42 highlighted the problems
of using sodium hypochlorite (NaOCl), the
most widely used irrigant in endodontics.
It is potentially damaging to clothing,
eyes, skin and oral mucosa and should
be used with care. Its positive effects at
concentrations of 0.5-5% in endodontics
are well documented and it is the only
worthwhile irrigant. Endodontics cannot
be expected to be successful without its
use despite the availability of such prod-
ucts as potassium iodide and chlorhexi-
dine, which are adjunctive to NaOCl. Many
practitioners use saline and/or local anaes-
thetic which in essence achieves nothing
other than lubrication. Hydrogen perox-
ide is a product of the past and its use is
never indicated.
However, when NaOCl is inadvertently
extruded through the apical foramen a
severe reaction can occur. This problem
is possible when the solution is injected
into the canal under pressure and with the
needle locked into the canal as the solution
is placed. Endodontic irrigating syringes
are available with luer-lock type attach-
ments and side vent needles to ensure that
the irrigant is injected laterally from the
needle under minimal pressure rather than
forced apically. While the needle should be
fine enough to be placed into the apical
one third (27-29G), it should always be
loose in the canal as the solution is placed.
In addition the needle should always be
kept on the move while irrigating.
If an accident occurs it can be rapid and
very severe, with intense pain despite a
local anaesthetic being in place. There will
be instant swelling and haemorrhagic exu-
date may well come into the canal from
the apical tissues. The event is more likely
to occur with upper central, lateral and
canine teeth but there are literature reports
of extrusion of the solution with damag-
ing effects into the maxillary sinus and
inferior dental (ID) canal. When the prob-
lem occurs, reassurance to the patient is
needed with advice on what is to be done:
increased local anaesthesia for additional
pain relief (block anaesthesia if needed),
washing of the canal copiously with saline
and then drying with paper points and clo-
sure of the canal but with no medication.
© 2010 Macmillan Publishers Limited. All rights reserved
PRACTICE
Fig. 11 Severe swelling and bruising as
a result of hypochlorite accident (image
originally published in Spencer et al. Br Dent J
2007; 202: 555-559)42
The patient will possibly have severe
swelling and bruising (Fig. 11). Analgesics
should be prescribed as well as such drugs
as dexamethasone and/or an antihista-
mine to suppress the inflammatory and
allergic aspects. It may be prudent to pre-
scribe antibiotics. Ask the patient to return
each day to evaluate signs and symptoms.
Telephone regularly to enquire about the
patient’s welfare. Immediate referral to a
hospital casualty department may well be
advisable if the reaction is severe and has
occurred in proximity to vital structures.
A hypochlorite accident is not inten-
tional but its consequences are severe.
Despite best efforts at palliative treatment,
a litigious patient may well seek compen-
sation and pursue a claim for negligence.
Always contact your defence organisation
for advice.
Obturation problems
Litigious situations under the heading of
obturation include overfilling, overexten-
sion, underfilling and poorly condensed
root filling to name various issues.
The requirements for a good root filling
are clearly stated in the ESE guidelines:
‘The objectives are: to prevent the passage
of microorganisms and fluid along the root
canal and to fill the whole canal system,
not only to block the apical foramina but
also the dentinal tubules and accessory
canals’. The root filling should be a semi-
solid material in conjunction with a root
canal sealer to fill the voids between the
167
PRACTICE
Fig. 12a 24 apical area requires root canal
treatment
filling material and the canal wall. The fill-
ing should be as close as possible to the
apex of the root. Voids should not be seen
either within the body of the root filling or
at the filling and canal wall junction.
Similarly, pastes are not acceptable to
fill root canals, especially those contain-
ing aldehydes (N2, Spad, Endomethasone).
Due to the flowable nature of some pastes,
extrusion is always a possibility and in
the lower jaw the inadvertent extrusion
of a paste into the ID canal with attendant
problems of partial or permanent paraes-
thesia would be indefensible.
Silver points are no longer accept-
able and the American Association of
Endodontists has published a position
statement on the use of this material.43
While accepted as a reasonable root fill-
ing material some 30 years ago, it should
not be used today as silver points corrode,
attract bacteria and perpetuate or cause
lesions of endodontic origin. If their use
caused a failure of treatment it would be
a difficult situation to defend.
Gutta percha is an acceptable material,
although were gross extrusion to occur
with symptoms and no radiograph had
been taken it would be difficult to defend.
If good length control has been shown to
have taken place – electronic apex loca-
tors used and a satisfactory working length
radiograph with file and/or GP exposed –
and extrusion occurs, it would be easier to
defend an allegation of negligence.
The fact is that modern techniques of pat-
ency and preparation to the apical foramen
with filling techniques based on heated
gutta percha will result, in some instances,
in excess material in the periapical tissues.44
While radiographically not very aesthetic,
these incidents are not necessarily the cause
of failure. Molven et al.45 reviewed many
168
Fig. 12b Good length control confirmed by
master cone X-ray. Good tugback ascertained Fig. 12c Despite overfilling of canals 24,
with GP points healing is seen at one year
root treated cases over a 27 year period and on the floor of the pulp chamber or within
showed many successful outcomes even in the confines of the root. The issue here is
the presence of overfilling and excess root that if, when starting a root canal, there
filling material (Figs 12a-c). Siqueira has is the likelihood of a difficulty that could
confirmed that bacteria are the cause of lead to one of the above scenarios, the
endodontic failure, not excess root fill- patient should be informed beforehand. If
ing material or a reaction to it, assum- you cannot locate a sclerosed canal and
ing a compatible material such as gutta you perforate attempting to find it but you
percha is used.46 had advised the patient beforehand that
Root fillings more than 2 mm short of this could happen there is little chance
the radiographic apex are more likely to a patient could successfully bring a case
fail than those at or flush with the radio-
graphic apex.47 Despite one’s best efforts
this scenario could happen. The problem
occurs when a restoration is placed on a
short root filled tooth. What is the likely
response from a patient should swelling
and pain ensue after the crown is placed
(Figs 13a and b)? The answer to the prob-
lem is communication. We are all entitled
to have a bad day but the patient must be
informed of all issues related to the final
outcome. Should you feel the endodontic
result does not justify an expensive crown, Fig. 13a 46 inadequately root treated.
Minimal radiographic evidence of endodontic
do not provide one. If you place a crown disease and the tooth is symptom-free.
then you must justify the endodontic out- An excellent restoration is placed. The option
come to the patient. It is unlikely that a of retreatment was never discussed with
the patient
patient will be happy if there is a prob-
lem after RCT and a crown. The poten-
tial for this problem should be explained
in advance.
Remember, an endodontic specialist is
always available to advise and if possi-
ble treat a case where the clinical result is
less than perfect. Of course a patient may
refuse a consultation or treatment with a
specialist. Record this fact. Communication
and record keeping is key in doing one’s
best within the confines of good practice.
Fig. 13b 46 at six months. Radiographic
Perforations endodontic disease is now apparent. The
While attempting to find a canal, a perfo- patient has pain and swelling and is certainly
not happy!
ration is always possible. This can happen
BRITISH DENTAL JOURNAL VOLUME 209 NO. 4 AUG 28 2010
© 2010 Macmillan Publishers Limited. All rights reserved

a b
c d
Fig. 14 a) 26 failing silver point case requires root canal retreatment and restoration.
b) Core material and silver points removed to show large perforation of long standing duration
on floor of pulp chamber. c) Four canals retreated and perforation sealed with ProRoot MTA
(Dentsply Maillefer). d) 26 at one year recall with core build up. Good apical healing and no
evidence of pocketing coronally or furcal breakdown related to sealed perforation. The tooth
can now be crowned
of negligence. Similarly, if you had rec- ease, are seen as an alternative. While the
ommended a referral which the patient cloud of litigation can affect the decision
declined but had recorded accurately your making process, endodontics can and should
conversation with the patient it is unlikely be successful. Only by ensuring standards
that further action would be successful. are maintained can we achieve the goal of
Current wisdom advises that in the case tooth retention and avoid the unnecessary
of a perforation, the use of MTA, a prod- trauma that accompanies a complaint for
uct which has been available since 1995, negligence from an irate patient.
is advisable.48 Do you have and do you 1. De Cleen M J H, Schuurs A H B, Wesselink P R, Wu
know what do to do with MTA or should M-K. Periapical status and prevalence of endodontic
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in the notes (Figs 14a-d). 238–245.
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